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Brittany Frisch
Dr. Robson
Bioethics
April 2008
2 Sides of the Story
In a world with new medical technology it is easy to treat almost any condition simply by taking a single pill. If your back hurts, you take aspirin; if you are having your monthly cramps, you try some Midol; and when it comes to something more serious like depression you go to your doctor for medical advice and a prescription that’s applicable to your condition. But the fact of the matter is some patients, despite medical advances in prescription drugs do not want to take any prescription or over-the-counter drugs to treat their mental illness, whether it is schizophrenia or depression. Dr. Signorelli writes, “Most physicians agree that patients should participate in decisions about their treatment” (Signorelli, 2007). Yet, some physicians still force psychiatric patients to take medications because, “There are situations in which a patient may not be competent to make decisions about his medical care” (Signorelli, 2007). After researching this topic I found it dramatically difficult to come to a moral decision regarding forcing medication so we will look at both sides of the argument.
You are the nurse taking care of a 45 year old man, Mr. "A", who was admitted to your medical nursing unit of a teaching hospital. Your patient was admitted for complications due to diabetes mellitus and hypertension. In report you are told that Mr. A has a history of psychiatric illness, but that he voluntarily stopped taking his psychotropic medications several weeks ago because he believed them to be poisonous. In fact, Mr. A has stopped taking all of his medications, including his blood pressure medicine and within the past couple of days, his insulin, because he believes them to be poisonous as well. Mr. A was admitted to the medical unit rather than the psychiatric unit because his primary problems at this time are medical in nature. Mr. A was originally treated in the emergency room and was given insulin for his high blood sugar.
Shortly after you complete your morning nursing assessment, you discuss performing an accucheck, and bring in Mr. A's morning dose of blood pressure medications, as well as his previously prescribed anti-psychotic medication. While you are in his room, the medical resident comes in to see Mr. A, but Mr. A tells the doctor to leave his room because he believes him to be an alien, and also states that he will not allow any "alien" tests to be done on him and that he will not take the medication you have for him because he insists that the medication is poisonous.
You leave the room and discuss the situation with the resident physician, who states that you must force Mr. A to take all of his medications as well as to perform an accucheck "whether he likes it or not" as the physician believes that Mr. A's life could be in danger if his blood sugar or his blood pressure get too high. As the physician leaves the unit, he orders a psychiatric consult as well. What do you do in this situation?
Physicians believe it is their duty to keep the patient safe, while the patients believe that what is safe for them should be decided by them not the physician. In most cases the physician knows what is best to be prescribed to treat an illness, but what the patient wants is to have a choice as to whether or not to accept the treatment. When it comes to having a surgery to get rid of breast cancer doctors always give the patient a choice if they want the surgery or if they want to wade the cancer out till it inevitably kills them. But when it comes to treating a mental illness like schizophrenia the physicians give the patient no choice. According to an individual’s belief and religion, taking medication may or may not be what the patient feels is the best action for treating their mental illness. Scientology for example rejects psychiatry and psychology as a resource for treating a mental illness. Dr. Brooks the vice president of the church of Scientology in Australia stated, “What the church of Scientology is against are brutal practices in the psychiatric field, practices that cause damage to the mind, the body and the brain, and practices that aren’t proven to handle the source of the problem.” (Elks, 2007)
In addition involuntary medication disregards the constitutional rights of the mentally ill patients. In many cases the first and fourteenth amendments are violated. The first amendment is the freedom of religious expression and the fourteenth amendment is the due process protection which allows all of a person’s legal rights to be respected by the government. Constitutional principles provide individuals with “bodily autonomy and integrity as well as freedom from bodily intrusions.” (Wettstein,2003) When a patient is forced to take medications the physician is violating the patient’s constitutional rights as well as disregarding laws set in place to protect patients. (Signorelli, 2007)
As well as violating patient’s personal rights, forcing medication on psychiatric patients can also hinder their abilities. Taking psychiatric medications have a wide variety of symptoms and problems that can arise from taking the medication. Psychiatric medications can hinder patients’ “exogenous mind, thoughts, and behavioral control” (Wettstein, 2003). Every drug has its own short term or long term effects that can participate in hindering a patient of the antipsychotic drug (Zimmer 1999). Many patients who take psychiatric drugs become depressed and commit suicide. (Psychiatric Information, 2006)
A diagnosable mental disorder is defined as “changes in thinking, mood, or behavior that distress or increase the risk of death, pain or disability.”(USA Today, 2001)
In 1998 Rodger Gambs who suffers from schizophrenia stole two of his father’s guns to arm himself from blood sucking vampires that lived in his back yard. Rodger refused medication. (Parker,2001) One of the most frustrating things for a family is having a family member who refuses to take their psychotropic medications. Patients with psychiatric disorders refuse to take their medication for a variety of reasons including experience and fear of side effects. It is understandable that patients don’t want to take something that causes them so much turmoil such as the side effects of some of the medications. The side effects of medication include but are not limited to excessive sedation, tremor, dry mouth, constipation, impotence, weight gain, and missed menstrual cycles. In some cases the patients refuse to take their medication because of a lack of awareness of their illness or delusional beliefs about their illness. Most patients suffering from psychotic mental disorders receive a sizable advantage by taking medication, yet some refuse. Those who chose to stop taking their prescribed medication often lose touch with reality and become psychotic again. In such cases that the patient believes that there is nothing wrong with them they are considered to be in denial. It is not surprising that patients with psychiatric problems go into denial. No one wants to be considered different and taking medication is an acknowledgement that there is something wrong with them which can be frightening to the patient. Some other times resistance to medication is a battle for control of their autonomy. Doctors and nurses can be so overwhelming for some patients with psychiatric disorders that the patients no longer feel that they have control over their lives.(Hatfield, 2004)
The reason why patients should be forced to take medication is because the mentally psychotic are not competent enough to make important decisions regarding their mental health. “Generally, hospitalized schizophrenic patients manifested significantly poorer understanding of informed consent disclosures about potential medication than did any other groups of patients.”(Lassiter, 2005) In many recent studies they found that 50% of individuals with psychiatric disorders have an impaired awareness of their illness. Patients mental illnesses impair the function of the prefrontal cortex. The prefrontal cortex is the part of the brain that is used for self-reflection. This means that patients with psychiatric disorders are as competent as individuals who have suffered a stroke or have impaired self-awareness.(Fuller, 2008) In a study 19 chronically ill patients who consistently expressed doubt about their need for medication provided more inflated estimates of their performance than 18 patients who did not express such skepticism.(Todman, 1997) At the moment the courts and doctors are allowed to force medication on patients in some states under certain circumstances.(Hausman, 2001) In response the American Psychiatric Association filed a brief for the government stating that “medications that restore a defendant to competency are often the most medically appropriate way of treating a mental illness.”(Psychiatric Services, 2003)(Veltkamp, 2008)
Although there are no laboratory tests to specifically diagnose mental illnesses, a doctor may use various tests to make sure something else is not causing the problems. Diagnosing the mentally ill involves many steps starting with an evaluation by a doctor. If during the evaluation the doctor finds symptoms of a mental illness he will then ask you questions about your symptoms, medical history, and then the doctor will perform a physical examination. If no other illness is found to be the problem then the doctor will refer the patient to a psychiatrist or psychologist. The psychiatrist or psychologist will use specifically designed interview techniques to assess and evaluate the patient. Based on what they learn they will then refer to the Diagnostic and Statistical Manual of Mental Disorders to diagnose the patient. (Chakraburtty, 2007)
By not forcing psychiatric patients to take medication the public is in danger. One person per week dies at the hands of a psychiatric patient. A report also revealed that 249 people were killed by patients released over the past 5 years. (Akbar, 2006) A national survey showed that the lifetime risk of schizophrenia was 5% among people convicted of homicide.(Friedman, 2006) There are many court cases involving involuntary medication including Sell v. United States in this case Sell was forced to take antipsychotic medication against his will and in doing so criticized the United States for forcing the medication.(Hayes,2004)
Because both sides of the argument have strong cases it is hard to determine the morality of forcing psychiatric patients to take psychotropic drugs.